Ask Dr. Pinson

This month's column features questions from readers.

Q: Following a total hip arthroplasty for a femoral neck fracture, a patient experienced
a drop in hemoglobin level from 11.5 g/dL to 8.4 g/dL. The clinician documented “precipitous
drop in hemoglobin” (ICD-10-CM code R71.0) and “likely bleeding due
to fractured hip.” The patient received one unit of packed red blood cells.
A history of “normocytic, normochromic (NCNC) anemia—improved since
last time” was documented in the admission note. Should I query the clinician
about whether the patient had acute blood loss anemia or just accept code R71.0?

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A: Code R71.0 for precipitous drop in hemoglobin is a nonspecific “symptom”
code, which should not be used when a related definitive diagnosis has been established.
It is primarily intended for the outpatient setting where the cause of the drop in
hemoglobin level is not yet known and requires further evaluation. It does have complication/comorbidity
(CC) status. However, an excludes-1 note for code R71.0 indicates that it cannot be
used when anemia (codes D50-D64) has been diagnosed. NCNC anemia is assigned as code
D64.9 (unspecified anemia), which is not a CC. Therefore, in this case, code R71.0
cannot be assigned. It is necessary to clarify that the drop in hemoglobin level represents
an acute blood loss anemia (code D62), which is a CC that impacts this diagnosis-related
group.

Q: We are frequently confronted with having to validate codes for acute respiratory failure
and acute pulmonary insufficiency. There seems to be widespread clinical agreement
regarding the clinical criteria for a diagnosis of acute respiratory failure. But
we frequently run into problems with pulmonary insufficiency and the lack of generally
agreed-upon criteria. I am seeing charts where some physicians are documenting a borderline
post-op SpO2 on a small amount of oxygen (saturation around 93% to 94% on 1 to 2 liters, for example)
as acute respiratory failure and others during the same stay are calling it respiratory
insufficiency. We then get questions later regarding whether or not acute respiratory
failure and insufficiency should be coded together. Can you help clarify these conditions?

A: As you said, respiratory failure is a well-defined clinical entity. Respiratory insufficiency
is a vague, nonspecific, undefined term that is probably intended to describe a respiratory
status that is not normal but does not quite reach the criteria for respiratory failure.
I see no objection to the use of the term in such circumstances. Respiratory failure
and insufficiency are not reported together since respiratory failure is a more specific
diagnosis.

Unfortunately, many clinicians continue to use “respiratory insufficiency”
indiscriminately and haphazardly without consideration of the authoritative diagnostic
standards for respiratory failure—a substantial educational challenge. Clinicians
should not be using a vague, nonspecific, undefined term like respiratory insufficiency
when the correct diagnosis is well defined and specific, like respiratory failure.
See Coding Corner in the July 2017 ACP Hospitalist for more details on this topic.

Q: We are having a tremendous internal discussion with our pulmonologists regarding the
inpatient coding pathway for bronchoalveolar lavage (BAL). They look at us as if we
have two heads when we ask them to differentiate if they went into the lobe of the
bronchus or the lobe of the lung. We're concerned about overcoding versus leaving
money on the table. Do you have any advice?*

A: The American Hospital Association's Coding Clinic is the official source for clarification
of ICD-10-CM. Coding Clinic First Quarter 2016, pages 26-27, gave the initial advice
that BAL (classified as a non-operating room [non-OR] procedure) is assigned as bronchial
(endobronchial) drainage (7th character “X”), not drainage of the lung.

Subsequently, Coding Clinic First Quarter 2017, page 26, changed this advice, stating
that “the lung body part values more accurately capture the objective of bronchoalveolar
lavage” and that code 0B9J8ZX (diagnostic drainage of left lower lung lobe)
is assigned for BAL of that location.

Fortunately, diagnostic BAL (drainage of the lung) is a non-OR procedure (7th character
“X”), so the diagnosis-related group will remain unchanged. It doesn't
matter whether clinicians document BAL of bronchus or lung as long as they specify
which lobe is being lavaged (e.g., BAL of left lower lobe bronchus, assign code for
left lower lobe of lung). No money is being left on the table.

Oddly, when bronchial drainage is performed for therapeutic purposes only (i.e., no
diagnostic specimen of any kind is collected and analyzed), it is classified as an
OR procedure even if done at the bedside (7th character “Z”), even though
the two procedures are identical except for collection of a specimen.

*The answer to this question has been corrected to note that BAL of the lung is considered
an OR procedure. The correction was published as a sidebar in the May 2018 ACP Hospitalist Coding Corner. Return to the corrected sentence.

Richard D. Pinson, MD, FACP, is a certified coding specialist, author, educator, and
cofounder of Pinson and Tang, LLC in Houston. If you have a documentation or coding conundrum, please write to us. Dr. Pinson answers questions from readers quickly, and some may be published.

ACP Hospitalist provides news and information for hospitalists, covering the major issues in the field. All published material, which is covered by copyright, represents the views of the contributor and does not reflect the opinion of the American College of Physicians or any other institution unless clearly stated.